How to Screen and Care for Homeless LGBT Youths

LGBT youths are grossly overrepresented in the homeless population. Despite only 8 percent of high school students identifying as LGBT,¹Kann L, Olsen EO, McManus T, Harris WA, Shanklin SL, Flint KH, et al. Sexual Identity, Sex of Sexual Contacts, and Health-Related Behaviors Among Students in Grades 9-12 – United States and Selected Sites, 2015. MMWR Surveill Summ. 2016;65(9):1-202. Epub 2016/08/12. doi: 10.15585/mmwr.ss6509a1. PubMed PMID: 27513843. nearly 40 percent of young people experiencing homelessness identify as a sexual minority.²Durso L, Gates G. Serving Our Youth: Findings from a National Survey of Services Providers Working with Lesbian, Gay, Bisexual and Transgender Youth Who Are Homeless or At Risk of Becoming Homeless [Internet]. Los Angeles: The Williams Institute; 2012. Available from: https://escholarship.org/uc/item/80×75033 Such disproportionate figures pose a unique challenge for the homeless youth organizations and service providers that care for this population. The consequences of homelessness can lead to lifelong cognitive, psychiatric, and social deficits, and physicians play an important role in mitigating and treating such effects.³Rosario M, Schrimshaw EW, Hunter J. Homelessness among lesbian, gay, and bisexual youth: implications for subsequent internalizing and externalizing symptoms. J Youth Adolesc. 2012;41(5):544-60. Epub 2011/06/10. doi: 10.1007/s10964-011-9681-3. PubMed PMID: 21656284; PubMed Central PMCID: PMCPMC3215813.^,4Baron S. Street Youth, Unemployment, and Crime: Is It That Simple? Using General Strain Theory to Untangle the Relationship. Canadian Journal of Criminology and Criminal Justice. 2008;50(4):399-434.

For health care providers, the first step in compassionate care for LGBT young people experiencing homelessness is being able to identify these patients. Because this population may be hesitant to disclose their homeless status out of fear of discrimination,⁵Christiani A, Hudson AL, Nyamathi A, Mutere M, Sweat J. Attitudes of homeless and drug-using youth regarding barriers and facilitators in delivery of quality and culturally sensitive health care. J Child Adolesc Psychiatr Nurs. 2008;21(3):154-63. Epub 2008/08/01. doi: 10.1111/j.1744-6171.2008.00139.x. PubMed PMID: 18667048. providers should try to assess if the patient’s listed address is temporary or permanent in order to determine housing stability. Asking questions like, “Is this address a place at which you are regularly able to stay?” can help solicit such information from the patient without assumptions, allowing for the patient to interpret what stability may look like for them. Furthermore, while intake forms should include demographic questions that ask for patient gender identity or sexual orientation, such questions should not be made a requirement. Empowering the patient to disclose such identities on their own terms helps to ensure their comfort with the health care team and results in a better patient-provider relationship.

The second step in caring for LGBT youths experiencing homelessness is assessing patient safety. Several studies show that homeless LGBT youths experience particularly high rates of physical and verbal abuse. In homeless youth housing programs with public showering facilities and high occupancy limits, for instance, LGBT youths have an increased risk of physical assault compared to their non-LGBT peers.⁶Woronoff R, Estrada R, Sommer S. OUT of the Margins: A Report on Regional Listening Forums Highlighting the Experiences of Lesbian, Gay, Bisexual, Transgender, and Questioning Youth in Care [Internet]. CWLA and Lambda Legal; 2006. Available from: https://www.lambdalegal.org/sites/default/files/publications/downloads/out-of-the-margins.pdf Another study found that all surveyed LGBT youths living in group foster care experienced verbal abuse and 70 percent experienced physical assault.⁷Feinstein R, Greenblatt A, Hass L, Kohn S, Rana J. Justice for All: A Report on Lesbian, Gay, Bisexual and Transgendered Youth in the New York Juvenile Justice System [Internet]. New York: Urban Justice Center; 2001. Available from: https://files.eric.ed.gov/fulltext/ED471676.pdf The reality of such disparities requires providers to be vigilant and thorough so as to protect patients from future harm. Assess whether a patient’s living situation is safe. Ask if they are staying with friends or persons that might be taking advantage of them. Is there violence or conflict in their place of residence? Additionally, consider their health risks as part of their safety. Ask about the patient’s medical conditions and past and current medications. If the patient is no longer on their parents’ insurance plan, inquire how they are accessing health care and ensure that any potentially life-threatening conditions are effectively managed.

Stabilization of mental and psychiatric issues among homeless youths correlates with increased employment and housing stability.

Although there is a clear trend toward increased acceptance of LGBT-identifying persons in America, stigma of sexual minorities persists. When combined with the traumatizing realities of homelessness, this stigmatization can result in significant risk for serious mental health disorders. Among LGBT homeless youths, nearly 40 percent report having one major depressive episode compared to 25 percent of those identifying as heterosexual. Similar figures emerge regarding suicide: sexual minority youths are 50 percent more likely to have had a lifetime suicide attempt than their heterosexual counterparts.⁸Whitbeck LB, Chen X, Hoyt DR, Tyler KA, Johnson KD. Mental disorder, subsistence strategies, and victimization among gay, lesbian, and bisexual homeless and runaway adolescents. J Sex Res. 2004;41(4):329-42. Epub 2005/03/15. doi: 10.1080/00224490409552240. PubMed PMID: 15765273. Establishing a safe environment can help to mitigate the psychological stress associated with stigmatization. This can be achieved by incorporating LGBT-specific content in mandatory staff training, adopting a standard practice of using affirming language and developing strong relationships with other LGBT-focused community organizations. Additionally, providers should implement rigorous mental health screening in their practice in order to detect any underlying mental health condition. Consider using the PHQ-9 and GAD-7 screening tools to assess for depression and anxiety as well as the Drug Abuse Screening Test to assess for substance abuse. Stabilization of mental and psychiatric issues among homeless youths has been shown to correlate with increased employment and housing stability.⁹Busen NH, Engebretson JC. Facilitating risk reduction among homeless and street-involved youth. J Am Acad Nurse Pract. 2008;20(11):567-75. Epub 2009/01/09. doi: 10.1111/j.1745-7599.2008.00358.x. PubMed PMID: 19128341.

Another common health problem among homeless LGBT youths is sexually transmitted infections. Homeless LGBT youths have an increased risk of acquiring sexually transmitted infections because they are more likely to engage in behaviors associated with a higher risk of contracting HIV and other STIs, including survival sex without condoms and injection drug use, and are more likely to be victims of sexual abuse.¹⁰Marshall B, Shannon K, Kerr T, Zhang R, Wood E. Survival Sex Work and Increased HIV Risk Among Sexual Minority Street-Involved Youth. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2009:1. The risk of STIs in this population presents a potential public health crisis that requires thorough intervention. A comprehensive sexual history should be taken as part of a broader psychosocial history that includes questions about the gender(s) and number of each patient’s past sexual partners. Providers treating LGBT homeless youths should screen every patient for sexually transmitted infections and perform intensive counseling on preventative measures and safe sex practices. However, providers should be aware that these patients may not have the same autonomy over their sexual health as their non-homeless, non-LGBT peers. Incorporating questions from the Quick Youth Indicators of Trafficking screening tool, such as “Have you ever received anything in exchange for sex?” or “Have you ever worked for someone who asked you to lie while speaking to others?” can help providers elicit from patients a history of sexual exploitation. If a patient is found to have a history of sexual victimization, the provider should care for any immediate needs, such as pregnancy and STI testing, and refer the patient to the National Human Trafficking Hotline, which can assist in finding important support services.

Providing homeless LGBT youths with peer advocates who are or have been homeless may increase patient trust in providers.

Finally, something that should not be overlooked when caring for sexual minority youths experiencing homelessness is access to health care. More than 60 percent of homeless youths report being medically uninsured. For those that are, transportation and a lack of knowledge of available resources may pose a barrier to care.¹¹Edidin JP, Ganim Z, Hunter SJ, Karnik NS. The mental and physical health of homeless youth: a literature review. Child Psychiatry Hum Dev. 2012;43(3):354-75. Epub 2011/11/29. doi: 10.1007/s10578-011-0270-1. PubMed PMID: 22120422. Other, more intricate obstacles decreasing access to care include fear of discrimination–particularly among those that use substances or identity as sexual minorities–and negative past experiences with the health care system.¹²Ensign J, Bell M. Illness experiences of homeless youth. Qual Health Res. 2004;14(9):1239-54. Epub 2004/09/28. doi: 10.1177/1049732304268795. PubMed PMID: 15448298. Consequently, this population may benefit from an integrated care model combining not only primary care services but also access to mental health services, social workers and case management. Furthermore, providing these patients with peer advocates who are or have been homeless may increase patient trust in providers and help these patients navigate complex aspects unique to their care, such as consent and referrals.¹³Christiani A, Hudson AL, Nyamathi A, Mutere M, Sweat J. Attitudes of homeless and drug-using youth regarding barriers and facilitators in delivery of quality and culturally sensitive health care. J Child Adolesc Psychiatr Nurs. 2008;21(3):154-63. Epub 2008/08/01. doi: 10.1111/j.1744-6171.2008.00139.x. PubMed PMID: 18667048.

LGBT homeless youths are a particularly vulnerable population that experience a variety of unique health challenges. In identifying and adequately treating these patients, providers can help them lead healthier lives.